NOTICE of PRIVACY PRACTICES for MEDICARE SUPPLEMENT POLICYHOLDERS This Notice of Privacy Practices ("Notice") describes how your personal health information may be used and disclosed, and how you may obtain access to this information. This Notice is only applicable to our Medicare supplement policyholders. Please read this Notice carefully and retain it for future reference. INTRODUCTION The provisions of this Notice apply to The Order of United Commercial Travelers of America ("UCT," "we" or "us"), a covered health plan as defined under the federal regulations regarding the privacy of health information. UCT will share the personal health information of its members as necessary to carry out treatment, payment and health care operations as permitted by law. UCT is required by law to protect the privacy of our members' personal health information and to provide our members with this Notice of our legal duties and privacy practices with respect to your personal health information. We are required to abide by the terms of this Notice as long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices when necessary and to make the revised Notice effective for all personal health information maintained by us. Copies of revised notices will be mailed to all current members. You may obtain copies of this Notice by calling us or mailing a request to: UCT, 632 N. Park St., Columbus, OH 43215. USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION Your Authorization. Except as outlined in this Notice, we will not use or disclose your personal health information for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing, unless we have already taken action in reliance on your authorization. Disclosures for Treatment. We will make disclosures of your personal health information as necessary for your health care treatment. For example, a doctor or health care facility involved in your care may request certain personal health information that we maintain in order to make decisions about your care. Uses and Disclosures for Payment. We will make uses and disclosures of your personal health information as necessary for the payment of your health care. For instance, we may use information regarding your medical procedures and treatment to process and pay your claims, to determine whether services are medically necessary, or to otherwise determine benefits under your health plan. We may also forward such information to another health plan that has an obligation to process and pay claims on your behalf, or to our business associates who assist us in the processing of your health care claims. Uses and Disclosures for Health Care Operations. As permitted by law, we will use and disclose your personal health information as necessary for our own health care operations, which include: business management, enrollment, underwriting, reinsurance, compliance, auditing, rating and other functions related to your health benefits plan. We may also disclose your personal health information to a health care facility, health care professional or other health plan for such things as quality assurance and case management, but only if that facility, professional or health plan has also had a patient relationship with you. Family and Friends Involved in Your Care. With your approval, we may occasionally disclose your personal health information to designated family, friends and others who are involved in your care, or in payment for your care, in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation, and we determine that a limited disclosure may be in your best interest, we may share limited personal health information with such individuals without your approval. If you have designated a person to receive information regarding payment of the premium on your Medicare supplement policy, we will inform that person when your premium is not paid. We may also disclose limited personal health information to a public or private entity authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of your care. Business Associates. Certain aspects of our business are performed through agreements with outside persons or organizations. These may include auditing, actuarial services, legal services, data management, etc. It may be necessary for us to provide some of your personal health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we will require these business associates, through a written agreement, to safeguard the privacy of your information. Communications with You. We may communicate with you regarding your claims, premiums, or other things connected with your policy. You may request to receive communications regarding your personal health information from us by alternative means or at alternate addresses (for example, if you do not want messages to be left on voice mail or correspondence sent to a particular address). We are only able to honor such requests if failure to do so will jeopardize your personal safety. You may make such requests in writing and send them to: UCT, Attention: Client Services, 632 N. Park St., Columbus, OH 43215. Your request must state why you believe that the disclosure of your information may endanger you. Other Health-Related Products or Services. We may use your personal health information to determine whether you might be interested in or benefit from treatment alternatives or other health-related programs, products or services that may be available to you as a UCT member. For example, we may use your personal health information to identify whether you have a particular illness and contact you to advise you that a disease-management program to help you manage your illness is available to you as a UCT member. We will not use your information to communicate with you about products or services that are not health-related without your written permission. We also will not sell your information to a third party for its marketing activities without your authorization. Information Received Prior to Enrollment. Before issuing a policy to you, we may request and receive from you and your health care providers personal health information. We will use this information to determine whether you are eligible to be covered under a policy and to determine your rates. We will protect the confidentiality of that information in the same manner as all other personal health information we maintain and, if we do not issue a policy to you, we will not use or disclose the information about you that we obtained for any other purpose. Research. There may be circumstances when we may use and disclose your personal health information for research purposes. For example, a research organization may want to compare types of claims between different health plans for a specific time period and will want to review claims data that we maintain. Whenever your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board (IRB) or privacy board that oversees the research, or by agreements of the researchers that limit their use and disclosure of our member’s health information. Other Uses and Disclosures. We are permitted (or in some cases required) by law to make certain other uses and disclosures of your personal health information without your authorization: We may release your personal health information for any purpose required by state or federal law. We may release your personal health information for public health activities, such as required reporting of certain diseases, injuries, births and deaths, and for required public health investigations. We may release your personal health information as required by law if we believe you to be a victim of abuse, neglect or domestic violence. We may release your personal health information to the federal Food and Drug Administration (FDA), if necessary, to report adverse events, product defects, or to participate in product recalls. We may release your personal health information, if required by law, to a government oversight agency conducting audits, investigations or civil or criminal proceedings. We may release your personal health information if required to do so by a court-issued or an administrative subpoena or discovery request (in most cases you will have received notice of such release from the party issuing the subpoena or discovery request). We may release your personal health information to law enforcement officials as required by law to report wounds, injuries and crimes. We may release your personal health information to coroners and/or funeral directors consistent with state law. We may release your personal health information if necessary to arrange an organ or tissue donation from you or for a transplant for you. We may release your personal health information for certain research purposes when such research is approved by an institutional review board with established rules to ensure your privacy (see Research provision above). We may release your personal health information if you are a member of the military as required by armed forces services, and we may also release your personal health information, if necessary, for national security or intelligence activities. We may release your personal health information to workers' compensation agencies, if necessary, for your workers' compensation benefit determination. Please note that the state in which you reside may have laws regarding the use and disclosure of personal health information that are more stringent than those under the federal privacy laws. Some examples are the use and disclosure of information relating to HIV/AIDS testing and treatment and treatment for substance abuse or mental illness. UCT will not use or disclose your personal health information in a manner not permitted under state law, if such law provides for greater protection of your information. RIGHTS THAT YOU HAVE Access to Your Personal Health Information. You have the right to copy and/or inspect much of the personal health information that we retain on your behalf. All such requests must be in writing and signed by you or your representative. We will charge a fee to cover the costs of copying and postage if you request a copy of the information. You may obtain a request form by calling Customer Service at (800) 848-0123, or by writing to us: UCT, Client Services, 632 N. Park St., Columbus, OH 43215. Amendments to Your Personal Health Information. You have the right to request us to amend or correct the personal health information that we maintain about you. We are not obligated to make all requested changes, but will carefully consider each request. In order to be considered by us, all amendment requests must be in writing, signed by you or your representative, and must state the reasons why you believe the amendment or correction is necessary. If we make an amendment or correction you request, we may also notify others who work with us and have copies of the original uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form by calling or writing to us: UCT, Client Services, 632 N. Park St., Columbus, OH 43215. Accounting for Disclosures of Your Personal Health Information. You have the right to receive an accounting (or record) of certain disclosures made by us of your personal health information after April 14, 2003. Requests must be in writing and signed by you or your representative. You may obtain forms for requesting an accounting by calling Customer Service at (800) 848-0123 or by writing to us: UCT, Client Services, 632 N. Park St., Columbus, OH 43215. There is no charge for the first accounting of disclosure request in any 12-month period. However, we will charge a cost-based fee for each subsequent accounting you request within the same 12-month period. Restrictions on Use and Disclosure of Your Personal Health Information. You have the right to request restrictions on certain uses and disclosures of your personal health information for treatment, payment or health care operations by notifying us of your request for a restriction in writing. We are not required to agree to your restriction request, but may consider reasonable requests, when appropriate. We retain the right to terminate a previously agreed-to restriction if we believe the restriction is no longer appropriate. If we terminate a restriction, we will notify you of such action. You also have the right to terminate, in writing or orally, any agreed-to restriction by sending such notice to: UCT, Attention: Client Services, 632 N. Park St., Columbus, OH 43215. Complaints. If you believe your privacy rights have been violated, you may file a complaint by writing to: UCT, Attention: Compliance Department, 632 N. Park St., Columbus, OH 43215. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., in writing within 180 days of a violation of your rights. We may not retaliate against you for filing a complaint. ADDITIONAL INFORMATION If you have questions or need further assistance regarding this Notice, you may contact Customer Service at (800) 848-0123 between the hours of 8:00 a.m. and 4:40 p.m., Eastern Standard Time. If you are a UCT member, you have the right to obtain a paper copy of this Notice of Privacy Practices even if you have requested a copy by e-mail or other means. EFFECTIVE DATE. This Notice of Privacy Practices is effective April 14, 2003. Copyright Notice © 2001-2002 Ohio Hospital Association, Bricker & Eckler LLP, The Quality Management Consulting Group, Ltd. All Rights Reserved
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